PROMPT: Encourage the candidates to follow a structured answer here. Prompt them along the ABCDE examination with time for the remaining questions. Aim for 3 minutes for this question. Note: for maximum marks the candidate should aim to be prompted minimally by the examiner.

Candidate Answer:  

Main concern: 

I would be most concerned about an intra-abdominal sepsis, given she is febrile, tachycardic and hypotensive. This may be as a result of a ruptured liver metastasis. 

I would urgently attend to this patient, ensure she is resuscitated following the sepsis six protocol, and I will assess her according to the ALS principles. 

I would ask the nurses to do repeat observations including oxygen saturations, respiratory rate, heart rate, temperature and blood pressure. 

Airway: 

I would communicate with the patient. If she is able to communicate, her airway is likely patent.  

Breathing 

As she is slightly hypoxic, I would put her on high-flow oxygen, 15L via a non-rebreathe mask initially, and then titrate as necessary. 

I would inspect the chest looking for signs of sepsis and increased respiratory effort including including accessory muscle use, tracheal tug, colour changes, sweating and audible wheezing. 

I would palpate and percuss for reduced chest expansion, tactile fremitus. I would palpate for reduced air entry or additional breath sounds. 

At this stage, I would request a CXR to look for any consolidation or pleural effusions. 

I would perform an ABG to assess her lactate. 

Circulation 

I would record her observations, particularly temperature, HR, BP. 

I would assess the patient for signs of shock including capillary refill time, assess pulse, JVP and listening to heart sounds. 

I would request IV access with 2 wide bore cannula in her antecubital fossa and take bloods- FBC, CRP, U&Es and a coagulation screen. 

As part of sepsis six I would send off a blood culture and commence her on broad-spectrum antibiotics. 

I would ensure she is catheterised to get an accurate fluid output. 

Disability 

I would assess her GCS and check her blood glucose. 

I would examine her abdomen at this stage, looking for abdominal distension, bowel sounds and signs of peritonism (rigidity, guarding). 

Exposure 

I would exposure from head to toe, looking for any obvious signs of sepsis or bruising. 

Summarise: 

This is a 56 year old female with breast cancer and liver metastases, who now complains of abdominal pain and distension.  

I am most concerned about intra-abdominal sepsis which could be secondary to a ruptured liver metastasis.  

Additional: 

She should be resuscitated according to the sepsis six protocoI, and I would alert my seniors as she many require urgent imaging and ITU care for vasopressor support. 

Bedside investigations would include blood cultures and full blood count, CRP and lactate.   

Imaging- ultrasound abdomen, CT abdomen-pelvis with contrast. 

Intervention- Ascitic taps or drains. Samples can be sent for MC&S. 

• Anaesthetics 
• Intensivists 
• General surgery 
• Interventional radiology 
• Palliative 

Treatment escalation plan and ceilings of care.